Clinical Risk Assessment: Identifying Patients at High Risk for Heart Failure

MARSHA BABB, RN, BSN, MS, CNOR

eart failure is a major health problem in the United States. Nearly 5 million patients in this country have heart failure, and almost 500,000 patients are diagnosed with heart failure for the first time each year.1 An estimated 1.1 million Americans will have had a new or recurrent acute myocardial infarction in 2008, and many survivors will experience lasting morbidity with progression to heart failure and death.2 The goals of heart failure management are to improve patient symptoms and quality of life, reduce morbidity and mortality, stop the progression of heart failure, reverse ventricular remodeling, and prevent further cardiac disease. Management of heart failure includes medical therapies and surgical interventions. Coronary artery bypass graft (CABG) procedures are performed on more than 515,000 patients a year.3 This surgical intervention is recommended for patients with severe multivessel disease and poor ventricular function who have a large amount of viable myocardium. Increasing evidence suggests that chronic left ventricular dysfunction due to viable but hibernating myocardium in patients with severe multivessel disease is relatively common. Furthermore, observational studies now support the notion that coronary bypass surgery can result in stabilization and often improvement in left ventricular function in selected patients.4 There is no cure for heart failure. Consequently, patients with heart failure have a disease trajectory that ends in death, which causes care requirements to differ for individual patients in the heart
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failure continuum of care (Figure 1). Perioperative nursing care for the heart failure surgical patient is delivered in the context of health promotionto reverse heart failure, health maintenanceto stop the progression of heart failure, and palliative carefor end of disease/ end of life. Increasing numbers of patients with high-risk characteristics are undergoing surgical interventions like CABG as part of their heart failure continuum of care. The severity of illness affects the observed outcomes of cardiac surgery, which must be adjusted for severity of illness to be useful for evaluating and improving quality of care.5 Accurate preoperative evaluation of the risk factors associated with heart failure after CABG surgery is important

ABSTRACT
Care requirements differ for individual patients in the heart failure continuum of care. Few tools exist that enable the bedside nurse to assess the cardiac surgical patient effectively. A quality improvement project was conducted at a level I trauma center in the mid-Atlantic United States to identify perioperative heart failure patients who do poorly after cardiac surgery. The surgical patient who is at high risk for adverse events after coronary artery bypass graft surgery can be identified by clustering 11 characteristics. Of 1,971 patients studied, 294 had adverse outcomes. Data indicated that any cluster of the characteristics was intensified when emergency status was added. Key words: heart failure, cardiac surgery, clinical risk assessment tool. AORN J 89 (February 2009) 273-288. AORN, Inc, 2009.

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Reversible heart failure NYHA* Class I

Medications Diet Risk reduction Exercise Surgery CABG *NYHANew York Heart Association

Severe heart failure NYHA Class III

Medications

NYHA Class II
Medications

NYHA Class IV
Medications Surgery Coronary artery bypass graft (CABG) Mitral valve repair Left ventricular (LV) aneurysm repair LV assist device Transplant

-Cardiac resynchronization therapy (CRT) -CRT with defibrillator -Implantable cardioverter defibrillator CABG CABG

Figure 1 Treatment optionsgeneral therapies, medical therapies, and surgical interventionsin the heart failure continuum of care.

for patients and their perioperative health care teams. Making quality assessments; developing effective risk-reducing strategies; and planning appropriate, timely interventions requires a quality improvement tool that is clinically relevant and easy to use. However, none exist that enable perioperative nurses to evaluate high-risk surgical patients undergoing CABG. Risk-adjustment tools for the surgical patient with heart failure include surgeon tools that only predict mortality rates and anesthesia tools that only adjust for risk in the delivery of anesthesia. Nursing has no quality improvement (QI) tools for evaluating the heart failure surgical patient. Without an appropriate assessment tool, it is difficult for perioperative nurses to effectively screen cardiac patients at risk for heart failure after CABG surgery. It is equally difficult to plan risk-reduction strategies and design effective nursing interventions for these patients.

operative heart failure at a level I trauma center in the mid-Atlantic region of the United States.

LITERATURE REVIEW
Mortality rates after CABG surgery are low, but a subset of patients exhibit postoperative complications, including prolonged contractile dysfunction, low output syndrome, perioperative myocardial infarction, and cardiac failure. These patients require more days of ventilatory support, experience longer stays in both the postoperative intensive care unit and the hospital, and have higher mortality rates.6 A prospective study by Rao et al6 examined the association between patient characteristics and heart failure as a cause of death in 4,558 patients who underwent CABG procedures. Nine independent predictors of low cardiac output syndrome were identified: poor ventricular function (ie, ejection fraction [EF] < 40%); reoperation; urgent surgery; female gender; diabetes mellitus; advanced age (ie, > 70); left main coronary artery disease; recent myocardial infarction and/or triple vessel disease; and hypertension or peripheral vascular disease.6 The Northern New England Cardiovascular

OBJECTIVES
This QI project had two objectives. The first objective was to identify perioperative heart failure patients at increased risk for adverse outcomes after CABG surgery. The second was to use the findings to make recommendations for an organized approach to nursing care for patients at low, medium, and high risk for peri-

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Disease Study Group (NNECDSG) prospectively studied 8,641 patients undergoing CABG surgery to determine the primary mode of death. Inhospital deaths were used to calculate mortality rates.7 During the study period, 384 patients died. Of these deaths, almost two-thirds were directly related to heart failure.7 Additional analysis revealed other significant predictors of fatal heart failure, including female gender; prior CABG surgery; EF < 40%; urgent or emergency surgery; advanced age (ie, 70 to 79 years, > 80 years); peripheral vascular disease; diabetes (ie, type I or type II); dialysis-dependent renal failure; and three vessel disease.7 The researchers used this information to develop a clinical risk assessment tool to identify CABG patients who are at increased risk for fatal postoperative heart failure.8 The NNECDSG Preoperative Calculation of Risk of Fatal Low Cardiac Output in CABG Patients clinical risk assessment tool was developed to identify and categorize patients by low, medium, and high risk for heart failure. The patients were categorized based on 11 characteristics: age 70 to 79; age > 80; female gender; prior CABG; emergency status (ie, medical factors relating to the patents cardiac disease that dictate surgery should be performed within hours to avoid unnecessary morbidity or death); urgent status (ie, medical factors that require the patient to stay in the hospital to have surgery before discharge); left ventricular EF < 40%; three vessel disease; diabetes (ie, currently treated with oral medications or insulin); peripheral vascular disease (eg, cerebrovascular disease including prior cerebrovascular accident [CVA], prior transient ischemic attack [TIA], prior carotid surgery, carotid stenosis by history or radiographic studies, carotid bruit, lower extremity bypass,

absent pedal pulses, lower extremity ulcers); and renal failure prior to surgery (eg, on peritoneal dialysis or hemodialysis).8 The tool is a simple scoring system ranging from 0 to 23 (ie, low risk: < 4; medium risk: 4-6; high risk: > 7). Patients with clinical risk scores between 0 and 3 are in the bottom 45.5% of risk, whereas those with clinical risk scores equal to or greater than 7 are considered to be in the top 10% of risk of death from heart failure. The consortium of eight hospitals in the NNECDSG found the NNECDSG tool to be an acceptable alternative to the logistic regression model, especially in bedside application. The clinical score has discrimination ability (ie, receiver operating characteristic clinical score = 0.75, 95% confidence interval 0.71-0.78). The correlation between the predicted risk obtained from the logistic equation and that obtained from the risk assessment tool was 0.99 (P < .001).8 In a recent study, the NNECDSG used the same clinical assessment tool to categorize patients by low, medium, and high risk for heart failure. Process strategies for each of the risk categories were developed using evidence from the literature and data gathered by the NNECDSG. Preoperative, intraoperative, and postoperative interventions were developed for low-, medium-, and high-risk groups. Overall mortality rates decreased from 3.12% to 2.33% and the death rate from low output decreased from 1.16% to 0.77%.8,9

METHODOLOGY
I used a correlational design and retrospective chart review in this QI project to identify a cohort of surgical patients at one facility. I used the Society of Thoracic Surgeons cardiac database to identify patients who had undergone CABG surgery between April 4, 2002, and July 6, 2005. I conducted a chart review on patients who had the following three variables related to adverse outcomes: more than 24 hours of ventilatory support with an endotracheal tube (ETT), more than 48 hours stay in the cardiovascular intensive care unit (CVICU), and
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more than five days stay in the hospital. Each patient was evaluated for low output failure using the NNECDSG clinical risk assessment tool. Patients were given a numerical rating between 0 and 23 based on their preoperative characteristics. Those patients with a score equal to or greater than 7 were considered at high risk of death from heart failure. Data collection was initiated after the institutional review board approved the project and use of the data collection tool (Figure 2). All records were kept confidential. After data were entered on a flow sheet, the medical record and account numbers were deleted and the code number alone was used for identification purposes. Study-patient files were not released to anyone other than me as the principle investigator. All project information was kept in the office of the patient care coordinator for cardiac surgery, which was locked
Patient Medical record number Account number Admission date: 05/06/2002 Surgery: 05/07/2002 Intensive care unit hours: 162 Discharge: 05/23/2002

when not in use. Data were kept onsite and downloaded to a disk until all publications were completed and then the patient information was destroyed. All descriptive and inferential statistical analyses were performed using the Statistical Package for the Social Sciences.10 Patients were grouped according to whether they had a risk score greater than or equal to 7. Chi-square analysis and Fisher exact tests were used to compare differences in proportions. Continuous variables were compared using a Student t test and Wilcoxon signed rank test depending on the data distributions. A simple linear regression model was used to determine the relationship between ETT and risk scores and between the length of stay in the CVICU (LOS-CVICU) and in the hospital (LOS-H) and risk scores, where the risk score was the independent variable and ETT, LOS-CVICU, and LOS-H were the outcome measures.
Tool # 15

Hospital length of stay: 16 Ventilation Hours: 112 Variable low output failure Age 70-79 Age > 80 Female Gender Prior CABG Emergency Urgent EF < 40% 3 vessel disease Diabetes PVD Renal Failure Comments: Fatal patient score 1.5 3.0 1.5 1.5 6.0 2.0 2.5 1.5 1.5 2.5 3.0

Patient data Age: Gender: Previous coronary artery bypass graft (CABG): Status: Ejection fraction (EF): Diseased Vessels (Dz): Diabetic: Peripheral vascular disease (PVD): PVD Type: Renal Failure:

80 Female No Elective 38% 2 Yes Yes > 75% Carotid No

Score 0 3.0 1.5 0 0 0 2.5 1.5 1.5 2.5 0 12.5 12.5

High Risk for Heart Failure All patient data collected according to Society of Thoracic Surgeon data definitions.
Figure 2 Sample data collection tool.

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RESULTS

Between April 2, 2002, and Group Differences in July 6, 2005, 1,971 patients underwent CABG surgery. Perioperative Outcomes Two hundred ninety-four n (%) experienced adverse outcomes All patients after undergoing their proce294 100 dures. Adverse outcomes after High-risk group with adverse outcomes CABG surgery were defined as Total 245 83.3 > 24 hours ventilatory support 240 98.0 > 24 hours of ETT intubation, > 48 hours length of stay in > 48 hours LOS-CVICU, and cardiovascular intensive care unit 216 88.2 > five days LOS-H. > 5 days length of stay in hospital 235 96.0 All patients with adverse Medium-risk group with adverse outcomes outcomes after CABG were Total patients 49 16.7 evaluated for low output fail> 24 hours ventilatory support 49 100.0 ure using the NNECDSG clini> 48 hours length of stay in cardiovascular intensive care unit 36 73.5 cal risk assessment tool. Of the > 5 days length of stay in hospital 47 96.0 294 patients with adverse outcomes after CABG, 245 (83%) were in the high-risk group (ie, scores > 7), putting them in the TABLE 2 top 10% for risk of death from Perioperative Outcomes heart failure. Forty-nine paStratified by Risk Group tients (17%) were identified at medium risk of death from High Medium heart failure. In addition, Outcomes risk risk P value Ventilatory 99% (n = 290) required > 24 support time 145.3 31.6 97.7 31.8 0.097 hours ETT intubation; Length of stay in 86% (n = 252) had LOS cardiovascular CVICU > 48 hours; and intensive care unit 194.0 33.6 170.2 108.0 0.906 96% (n = 282) had LOS-H > Length of stay in 5 days. hospital 17.4 2.6* 11.0 2.0** 0.006* In the high-risk group, * high risk 98% had ETT intubation > ** medium risk 24 hours, 88% had LOS-CVICU > 48 hours, and the other outcomes. Ventilation times for high96% had LOS-H > 5 days. risk patients averaged 145.3 hours, compared In the medium-risk group, with 97.7 hours for medium-risk patients. The length of stay in the CVICU for the high-risk 100% had ETT intubation > 24 hours, 74% had LOS-CVICU > 48 hours, and patient was 194.0 hours, compared to 170.2 96% had LOS-H > 5 days (Table 1). hours for medium-risk patients. Table 2 presents the perioperative outcomes A snapshot of the high-risk patient for adstratified by risk group. For the high-risk verse outcomes after CABG by risk factor is patient with adverse outcomes after CABG, shown in Table 3. High-risk patients were the mean hospital length of stay was 17.4 days. more likely to be emergency cases (100%), be It was 11.0 days for those at medium risk with older than 80 years (98%), and have renal failcomplication. There was a significant differure (95%). The medium-risk patient with ence (P = .006) between the two groups for the adverse outcomes after CABG accounted for mean LOS-H, but no significant differences in 25% of urgent cases, 17% of cases with three
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TABLE 1

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TABLE 3

Percentage of Patients with Risk Factor by Risk Group

Risk factor
Age 70-90 Age > 80 Female gender Prior coronary artery bypass graft Emergency Urgent Ejection fraction < 40% Three vessel disease Diabetes Peripheral vascular disease Renal failure * high risk ** medium risk

Total
97 41 89 19 103 170 157 277 140 144 20

High-risk group n (%)

90 40 82 17 103 128 148 231 127 135 19 92.8 97.6* 92.1 89.5 100.0* 75.5 94.3 83.4 90.7 93.8 95.0*

Medium-risk group n (%)

7 1 7 2 0 42 9 46 13 9 1 7.2 2.4 7.9 10.5** 0.0 24.7** 5.7 16.6** 9.3 6.3 5.0

vessel disease, and 11% of cases that were repeat CABG procedures. The results of the univariate analysis (ie, a snapshot of the 252 patients with LOS-CVICU > 48 hours) revealed notable differences between the two groups (Table 4). Of the 252 patients, 50% were diabetic (P = .045) and 56% had EF < 40% (P = .07). The strongest predictors of ETT intubation > 24 hours were emergency patients with medical factors relating to their cardiac disease that dictated surgery should be performed within hours to avoid unnecessary morbidity or death. Emergent cases were 1.6 times more likely to require ETT support > 24 hours than nonemergent cases (Table 5). Moderate predictors of ETT support > 24 hours included ages between 70 and 79; urgent admission, diabetes (ie, currently treated with oral medication or insulin); peripheral vascular disease (eg, cerebrovascular disease, stroke, prior TIA, prior carotid surgery, carotid stenosis, carotid bruit); and lower extremity disease (eg, claudication, amputation, prior lower extremity bypass, absent pedal pulses, lower extremity ulcers). The strongest predictors of LOS-CVICU > 48 hours included eight of the patient characteristics listed on the NNECDSG tool. These were age > 80, female gender, emergency, left ventricular EF < 40%, three vessel disease, diabetes,

peripheral vascular disease, and renal failure. Moderate predictors included age between 70 and 79, prior CABG, and urgent admissions. The strongest predictors for LOS-H > five days included age > 80, urgent admission, and diabetes. Moderate predictors of LOS-H > five days included ages between 70 and 79, female gender, prior CABG, emergency admission, EF < 40%, peripheral vascular disease, and renal failure (Table 6).

SUMMARY
Mortality rates after CABG surgery are low, but a subset of patients exhibits postoperative complications that increase the risk of fatal heart failure.6 These patients are more likely to need ventilatory support and have longer stays in both the hospital and the postoperative intensive care unit. As the risks of surgery have decreased, cardiologists and surgeons have extended the benefits of CABG procedures to more patients. Consequently, an increasing number of patients with high-risk characteristics are undergoing CABG procedures. The care requirements for these high-risk patients differ from those of lower-risk patients, and it is important for perioperative nurses to effectively screen cardiac patients at risk of heart failure after CABG surgery. The first objective of this QI project was to

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TABLE 4

Univariate Analysis for Length of Stay in the Cardiovascular Intensive Care Unit (CVICU)
CVICU > 48 hours Yes No n (%) n (%)
Patients 252 79 173 39 213 80 172 126 126 89 163 144 108 140 112 85.7 31.3 68.7 15.5 84.5 31.7 68.3 50.0* 50.0* 35.3 64.7 57.8 42.9 55.6* 44.4* 42 18 24 2 40 9 33 14 28 14 28 26 16 17 25 14.3 42.9 57.1 4.8 95.2 21.4 78.6 33.3 66.7 33.3 66.7 61.9 38.1 40.5 59.9 0.14197 0.0635

P value

Age
70-79 All other ages > 80 All other ages

Gender
Female Male 0.17785

Diabetes
Yes No 0.04526*

Emergent
Yes No 0.80295

Urgent
Yes No Yes No * high risk 0.56289

Ejection fraction < 40%

0.06972*

identify perioperative heart failure patients at increased risk for adverse outcomes after CABG surgery using the NNECDSG clinical risk assessment tool. Of the 294 patients with adverse outcomes after CABG, 83% were in the high-risk group. The high-risk patients had longer ETT intubation times, extended LOSCVICU, and a mean LOS-H of 17.4 days. This subset of patients is small (n = 294; N = 1,971), but the resources consumed are huge. Logically, the patients at low and medium risk for fatal heart failure move through the system consuming resource dollars at a much lower rate. Accurate preoperative evaluation of the risk factors associated with heart failure after CABG surgery is important to perioperative health care teams in developing risk reduction strategies, designing effective nursing interventions, and using resources appropriately for high-risk patients. By risk factor, the high-

risk patient is more likely to be emergent, > 80 years old, and have renal failure. Emergency admissions are 1.6 times more likely to require ETT support > 24 hours than nonemergent admissions. There are notable differences between the high- and medium-risk patients with regard to LOS-CVICU. Of 252 patients (ie, the high-risk patients), 50% were diabetic (P = .045) and 56% had an EF < 40% (P = .07). Eight patient characteristics were strong predictors of LOS-CVICU > 48 hours. They include emergency, age > 80, renal failure, diabetes, EF< 40%, female gender, three vessel disease, and peripheral vascular disease. Three risk factors affect LOS-H: age > 80, diabetes, and urgent admission. A snapshot of the high-risk patient for adverse outcomes after CABG surgery includes a cluster of eight characteristics: age > 80 years; female gender;
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emergency admission; EF < 40%; three vessel disease; diabetes; peripheral vascular disease; and renal failure. The second objective was to use the find-

ings to make recommendations for an organized approach to nursing care for patients at low, medium, and high risk for perioperative heart failure. Of the eight strongest predictors, 100% of the emergency patients were at highrisk for perioperative heart failure. Clusters of characteristics adding up to a score of greater

TABLE 5

Odds Ratios for Ventilatory Support (ETT), Length of Stay in Cardiovascular Intensive Care Unit (LOS-CVICU), and Length of Stay in Hospital (LOS-H)
n = 294
Age 70-79 All other > 80 All other

ETT > 24 hours LOS-CVICU > 48 hours Yes No Odds ratio# Yes No Odds ratio
95 195 41 249 89 201 19 271 102 188 167 123 154 136 273 17 138 152 142 148 19 271 2 2 0 4 0 4 0 4 1 3 3 1 3 1 4 0 2 2 2 2 1 3 NA .4872 .07-3.51 Not applicable (NA) 79 173 39 213 80 172 15 236 89 163 144 108 140 112 239 13 126 126 125 127 19 233 18 24 2 40 9 33 4 39 14 28 26 18 75 25 38 4 14 28 19 23 1 41 0.8089** 0.31-1.19** 3.662* 0.85-15.78* 1.705* 0.78-3.73* 0.62** 0.20-2.0** 1.1* 0.55-2.18* 0.8205** 0.42-1.60** 1.8382* 0.95-3.57* 1.9352* 0.60-6.25* 2* 1.00-4.0* 1.19* 0.62-2.30* 3.34* 0.44-25.67*

LOS-H > 5 days Yes No Odds ratio

92 190 40 242 85 197 18 264 98 184 184 118 149 133 265 17 136 148 137 145 19 263 5 7 1 11 4 8 1 11 5 7 6 6 8 4 12 0 4 8 7 5 1 11 0.6779** 0.21-2.2** 1.8182* 0.23-14.47* 0.8629** 0.253-2.94** 0.70** 0.09-6.14** 0.7457** 0.23-2.41** 1.3898* 0.44-4.42* 0.5602** 0.16-1.90** NA

Gender
Female Male Yes No

Prior coronary artery bypass graft

NA

Emergency
Yes No 1.6277* 0.17-15.85* 0.4526** 0.05-4.40** 0.3775 0.04-3.67 NA

Urgent
Yes No Yes No Yes No

Ejection fraction < 40% 3 vessel disease Diabetes

Yes No Yes No Yes No 0.9079 0.13-6.53 0.9595 0.13-6.90 0.2103 0.02-2.12 1.863* 0.55-6.33* 0.6749** 0.21-2.18** 0.7947** 1.0-8.5**

Peripheral vascular disease Renal failure

* high risk ** medium risk # Odds ratio 95% confidence interval

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than 7 on the NNECDSG tool were accurate preoperative predictors for perioperative heart failure in CABG surgical patients. The cluster of patient characteristics may include diabetes, low EF, female gender, and peripheral vascular disease. The cluster may include women older than 80 years of age with peripheral vascular disease and renal failure. The cluster may include patients with renal failure who are older than 80 years of age, have peripheral vascular disease, and have to be worked up on urgent status with two or three consultations. Any cluster of these 10 characteristics was intensified with the emergency characteristic added to it.

TABLE 6

Odds Ratios for Ventilatory Support (ETT), Length of Stay in Cardiovascular Intensive Care Unit (LOS-CVICU), and Length of Stay in Hospital (LOS-H)
Risk factor ETT support LOS-CVICU LOS-H > 24 hours > 48 hours > 5 days
NA* strong moderate moderate NA weak weak moderate NA moderate NA strong strong strong strong strong strong strong moderate strong moderate moderate strong moderate strong moderate moderate moderate moderate strong NA moderate moderate

Age > 80 Emergency Diabetes Peripheral vascular disease Female Ejection fraction < 40% Renal failure Urgent 3 vessel disease Age 70-79 Prior coronary artery bypass graft * NA = not applicable.

LIMITATIONS/FUTURE INVESTIGATION
Multivariable analyses may have been more effective in determining the independent predictors of outcomes had the entire population of 1,971 CABG surgical patients been observed as opposed to only those with adverse outcomes. An increase in sample size would decrease the length of the confidence interval without decreasing the level of confidence, rendering more homogeneous or precise results. The high-risk patient would be even more visible against the background of low- and medium-risk patients. Future projects should be expanded to compare patients in whom the outcomes of interest occurred and patients in whom they did not.

OUTCOMES MANAGEMENT
Heart failure is a major cause of morbidity and mortality after CABG surgery. To adjust care strategies to patients undergoing CABG procedures who are at low, medium, and high risk for heart failure, perioperative nurses need cluster information, which identifies risk states before surgical intervention. The benefits

of preoperatively identifying this cohort of surgical patients for specific outcomes includes improving the quality of nursing care, establishing best practice for patients undergoing CABG procedures, helping to develop educational programs, identifying and analyzing interventions that contribute to specific patient outcomes, determining care requirements for a special needs population, and providing a basis for developing best practice guidelines. IMPROVING THE QUALITY OF NURSING CARE. One benefit of preoperatively identifying patients who are at risk of heart failure is improving the quality of nursing care at the bedside by translating research evidence into best practices in a timeefficient manner. In this QI project, 100% of the high-risk patients were emergent. Of these, 50% were diabetic and 56% had low ejection fractions with extended stays in the CVICU and the hospital. These findings initiated a review of the cardiac suites and their readiness to receive this cohort of patients at my facility. Revascularization is the priority, and reducing the time it takes to move the patient from
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the community, through the emergency department and the catheterization laboratory, and to the OR is imperative for best patient outcomes. Ideally, the door-to-incision-to-pump time will be within a 90-minute window so the patient can be revascularized immediately. Locating equipment, supplies, and medications should not be an issue in caring for an emergency patient. Too many times, nurses have to locate instruments, linen, and medications. As a result of this QI project, nurses at my facility have become more accountable for room preparation, and responsibility for resetting the rooms became a priority of care for the call teams. ESTABLISHING BEST PRACTICE. Identifying patients at high risk for heart failure also helps establish best practices for patients undergoing CABG surgery. Evidence suggests that perioperative management of diabetes literally levels the playing field for the cardiac patient with diabetes.11 Of the high-risk patients in this population, 50% were diabetic and had extended stays in the CVICU and the hospital. The diabetic patients in this group were slow to heal, had difficulty maintaining core temperature after bypass, and were prone to infection. This picture was intensified in a subset of patients who were also emergent. As a result of this QI project, particular attention was focused on the timeliness of obtaining blood gas values and blood glucose levels with a view toward the procurement of insulin drips for better intraoperative management. In addition, a required part of the preoperative protocol is timely administration of antibiotics. All of the patients at my facility, whether diabetic or not, receive antibiotics in a 30minute window before incision for preventing infection. This QI project emphasized the numbers of emergency patients who are diabetic that come through our facility. The intention is to level the playing field for the diabetic patient so that antibiotics work as they would in a nondiabetic patient. OBTAINING OBJECTIVE INFORMATION. Obtaining objective information for planning organizational resources includes assigning expert nurses who have strong clinical grasp (ie, clinical inquiry in action, including problem identification and

clinical judgement across time about the particular transitions of particular patients clinical situations) and clinical forethought and are able to anticipate actions and plans relevant to a particular patients possible trends and trajectories. The patient at high risk for heart failure requires perioperative nurses who become competent as quickly as possible; this patient requires an expert nurse who is competent and experienced with this patient group. Clinical forethought is second nature to the expert nurse who has local specific knowledge, such as how to marshal support services or equipment. Expert nurses prepare for specific patient populations, anticipate their special needs, and save essential time. Expert nurses also situate patients problems almost like a map or picture of possibilities using clinical judgment in conjunction with valid science.12 Logically, patient safety would demand a mixture of expert and competent cardiovascular OR nurses staffing the call teams. Evidence suggests that the flow of knowledge may result not only from best evidence but also from direct experiential learning in practice, thereby improving patient outcomes.12 DEVELOPING EDUCATIONAL PROGRAMS. Developing educational programsincluding orientation and training programs that specifically teach perioperative nurses about the patient who is at high risk for heart failurecan increase staff member satisfaction and reduce staff member turnover by promoting effective staffing patterns. Refining clinical judgment is possible when cardiovascular OR nurses have the opportunity to work with the cohort of patients discussed here. Evidence suggests that understanding the characteristic patterns of this particular patient population assists with recognizing shifts in a patients disease trajectory.11 Hence, an important part of orientation is a cohesive presentation on our facilitys Heart Failure Continuum of Care and the appropriate surgical interventions throughout the continuum. An orientation program for both experienced and inexperienced staff members ensures entry into the service line at a competent level without overwhelming the new employee or frustrating seasoned staff members. Evidence suggests that acuity-based assignments (ie, matching the difficult or sick

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patients with expert nurses as a product of competencyesearch findings are translated into practice to improve clinical based programs) produces 13 care. It is daunting to think that it takes an average of 17 years better patient outcomes. to move research findings into practice.1 This quality improvement IDENTIFYING AND ANALYZING project reduced this very large research-practice gap. These findings INTERVENTIONS. To continuously and lessons learned closed the gap and set nurses up for success in improve a practice, different their clinical practice. After this project, our nurses are SMARTER: clinical interventions and the Screen patients effectively with better tools consequent outcomes must be Manage high risk patients with best evidence compared. The goal is for Adopt new evidence based strategies for patient groups nursing practice to be a self Recognize change in disease trajectory in heart failure patients improving practice through Take evidence more seriously science and experiential clini Engage patients and colleagues alike cal learning and correction, Research, research, research rather than a closed or deteri1. Melnyk BM, Fineout-Overholt E. Evidence-Based Practice in orating tradition that repeats Nursing & Healthcare. Philadelphia, PA: Lippincott Williams & 12 errors. Wilkins; 2005: xxi. Additional preparation is required for this cohort of special needs patients. For example, when DETERMINING CARE REQUIREMENTS. Helping to deterthe patient is not able to wean off bypass, there mine care requirements for this population is a 90-minute window of opportunity to insert includes allocating specific support services a ventricular assist device, which is considered effectively, including point-of-care testing; spea surgical intervention for end-stage heart failcial instrumentation; and pharmacy, x-ray, ure. Evidence suggests that this population has transfusion, and OR liaison services. Structured better outcomes within that 90-minute wincommunication is particularly important for the dow.14 Intraoperative actions need to be taken cardiovascular OR service line. A DATAS report for this intervention to be successful, including (ie, demographics, assessment, tests, alerts, and obtaining family consent, considering bridgestatus report) facilitates hand-off communicato-destination (ie, for heart transplant or to tion on patient condition from the emergency recover the native heart), and determining department to the OR for trauma patients. Curavailability of equipment to perform a ventric- rently, there is a cardiovascular OR DATAS reular assist procedure. port, but the report is generated from the comNursing practice is improved by addressing munity to the emergency department to the preconceptions, expectations, and routines concatheterization laboratory, and does not contincerning the emergent patient and by adding ue to the OR. At our facility, a cardiovascular new insights applicable to this particular OR DATAS report is under consideration for patient situation. For example, an urgent the emergency patient in the acute coronary patient who cannot leave the hospital without syndrome protocol. surgery, requires several consultations, and DEVELOPING EVIDENCE-BASED PRACTICE. I disseminathas two or more heart failure characteristics ed the findings of this QI project to the newly needs to be expedited when the consultations formed Cardiovascular Surgical Outcomes are completed. Using the Society of Thoracic Committee at our facility. The Center for Heart Surgeons definition, revascularization is the and Vascular Health developed this committee priority depending on the cluster of character- to organize and advance care for the cardioistics.4 A snapshot of this patient comes from vascular service line based on outcomes reclustering the characteristics that identify this search. The committee membersoutcomes subset of patients in a meaningful way for research staff members including statisticians, perioperative assessment, measurable outsurgeons, cardiologists, and other physicians comes, and quality interventions.13 commented on our findings and how they will

Setting Nurses Up for Success

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contribute to the service line, especially with regard to bedside nursing. The project inspired confidence in perioperative nurses and their ability to work in a collaborative fashion with the physician groups. After I presented the information from the QI project, several subsequent projects were discussed for collaborative efforts to solve related problems. These projects included blood transfusion therapies, blood utilization, and the patient who has to return to the OR for bleeding or tamponade. In addition, I was asked to review my facility's bring back rate with a focus on how to reduce the number of blood products and platelet-rich products infused, as well as how to reduce the amount of renal failure. The first priority was to collect data on the patients who return to the OR for bleeding. In reviewing the literature, I learned of thromboelastography (ie, a point-of-care test that analyzes whole blood hemostasis, providing results that help distinguish between surgical site bleeding and bleeding from coagulopathy) and introduced it to my facility to help identify our patients at high risk for bleeding during and after cardiac surgery.

Patient safety requires improving the tools for perioperative nurses to do their work more efficiently and effectively. A lack of tools breeds fragmentation and inconsistency in the heart failure continuum of care. Structured communication and cluster information tools would enhance patient safety by obviating preventable error. Editors notes: This project was supported by a grant from AORN. The findings reported here are from a specific geographic area using databases specific to that population. Acknowledgements: The author thanks Linda Bucher, RN, PhD, professor of nursing at the University of Delaware, Newark, DE, and Paula Klemm, RN, PhD, ONC, associate professor of nursing at the University of Delaware, Newark, for their mentoring skills in the Young Scientist program, which assists bedside nurses in developing research skills for improving patient care at the bedside. The data analyst Malaika Omowale-McQuiller, MBA, was very helpful in shaping the topic and analyzing the data. The author also thanks Christiana Care for supporting my efforts in conducting this project to its successful completion.

LESSONS LEARNED
Accurate preoperative assessment to identify this cohort of patients (ie, those at high risk for heart failure after CABG) enables the cardiovascular OR nurse to deliver seamless care within AORNs patient-focused model. Targeting this population encourages the development of risk-reducing strategies, improving the quality of nursing care at the bedside and improving patient outcomes while reducing health care costs. The person in the charge role makes acuitybased assignments by considering which patients are at high risk for heart failure, and uses that information to plan organizational resources and assign a blend of expert and competent cardiovascular OR nurses to the call teams for better patient outcomes. The highrisk patient is in the OR longer, which directly affects staff members. Nurses need accurate cluster information for quality assessments, measurable outcomes, meaningful interventions, and applicable resource allocation.

REFERENCES 1. Heart Disease and Stroke Statistics2003 Update. American Heart Association; 2002. http://www .americanheart.org/downloadable/heart/1059 0179711482003HDSStatsBookREV7-03.pdf. Accessed November 11, 2008. 2. Bolli R, Becker L, Gross G, Mentzer R Jr, Balshaw D, Lathrop DA; NHLBI Working Group on the Translation of Therapies for Protecting the Heart from Ischemia. Myocardial protection at a crossroads: the need for translation into clinical therapy. Circ Res. 2004;95(2):125-134. 3. National Center for Health Statistics. Inpatient surgery. Centers for Disease Control and Prevention. May 1, 2003. http://www.cdc.gov/nchs/fastats /insurg.htm. Accessed November 11, 2008. 4. ACC/AHA 2004 guideline update for coronary bypass graft surgery: summary article. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for Coronary Artery Bypass Graft Surgery). Circulation. 2004;110:1168-1176. http://www.circ.ahajournals .org/cgi/content/full/110/9/1168. Accessed November 11, 2008. 5. Jones R, Hannan E, Hammermeister K, et al.
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Identification of preoperative variables needed for risk adjustment of short-term mortality after coronary artery bypass graft surgery. The Working Group Panel on the Cooperative CABG Database Project. J Am Coll Cardiol. 1996;28(6):1478-1487. 6. Rao V, Ivanov J, Weisel RD, Ikonomidis JS, Christakis GT, David TE. Surgery for acquired heart disease: predictors of low cardiac output syndrome after coronary artery bypass. J Thorac Cardiovasc Surg. 1996;112:38-51. 7. OConnor GT, Birkmeyer JD, Dacey LJ, et al; Northern New England Cardiovascular Disease Study Group. Results of a regional study of modes of death associated with coronary bypass grafting. Ann Thorac Surg. 1998;66(4):1323-1328. 8. Surgenor SD, OConnor GT, Lahey SJ, et al; Northern New England Cardiovascular Disease Study Group. Predicting the risk of death from heart failure after coronary artery bypass graft surgery. Anesth Analg. 2001;92(13):596-601. 9. The Northern New England Cardiovascular Disease Study Group. 2003. http://www.nnecdsg.org /study_sum.htm. Accessed November 11, 2008.

10. Statistical Package for the Social Sciences.

Chicago, IL: SPSS.

11. Furnary AP. Update on the Portland Protocol (slides with transcript). Selection from: From inpatient to outpatient: practical strategies for optimizing treatment of hyperglycemia and type 2 diabetes Mellitus. Slide 9. Medscape Today. http://www.med scape.com/viewarticle/570033. Accessed December 29, 2008. 12. Melnyk BM, Fineout-Overholt E. Evidence-Based Practice in Nursing & Healthcare. Philadelphia, PA: Lippincott Williams & Wilkins; 2005:168-181. 13. Petersen C, ed. Perioperative Nursing Data Set, 2nd ed rev. Denver, CO: AORN, Inc; 2007:141-143, 158163. 14. Abiomed Protocol Book [CD]. Danvers, MA: ABIOMED; 2006.

Marsha Babb, RN, BSN, MS, CNOR, is a cardiac surgery staff nurse at Christiana Care Health System, Newark, DE.

Diabetic Patients Manage Blood Pressure Better with Help

urses and pharmacists involved in a communitybased intervention for patients who have diabetes and hypertension can help these patients manage their blood pressure, according to a study in the November 24, 2008, issue of Archives of Internal Medicine. The study involved 227 participants from 14 community pharmacies in Edmonton, Alberta, Canada, who had diabetes and blood pressure higher than 130/80 mm Hg on two consecutive visits two weeks apart. Researchers gathered data between May 5, 2005, and September 1, 2006. Participants were randomly divided into an intervention group and a control group. Participants in the intervention group received care from a nurse and pharmacist team, which included a wallet card with recorded blood pressure measures, cardiovascular risk reduction education and counseling, a hypertension education pamphlet, referral to the patients primary care physician for further assessment or management, a one-page evidence summary sent to the physician reinforcing the guideline recommendations for treating hypertension and diabetes, and four follow-up visits during a six-month period.

Participants in the control group received a blood pressure wallet card, a pamphlet on diabetes, general diabetes advice, and usual care by their physician. Researchers measured the difference in systolic blood pressure changes between the two groups at six months. At the beginning of the trial, the mean patient age was 64.9 years (standard deviation [SD] 12.1) and the mean systolic/diastolic blood pressure was 141.2 (SD 13.9)/77.3 (SD 8.9) mm Hg. Nearly 60% of patients in the trial were male. After six months, the intervention group had a greater adjusted reduction in systolic blood pressure than the control group (P = .008). In a subgroup of patients whose systolic blood pressure was greater than 160 mm Hg at baseline, the reduction in systolic blood pressure was even greater in the intervention versus the control group (P < .001).
McLean DL, McAlister FA, Johnson JA, et al. A randomized trial of the effect of community pharmacist and nurse care on improving blood pressure management in patients with diabetes mellitus. Arch Intern Med. 2008;168(21): 2355-2361.

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